Solitary plasmacytomas
These are often treated with radiation therapy. If the plasma cell tumor is not in a bone, it may be removed with surgery. Chemo is only used if multiple myeloma develops.
Early myeloma
Early myeloma includes smoldering myeloma and stage I disease. Patients with early myeloma can do well for years without treatment. Starting treatment early does not seem to help them live longer. These patients are often watched closely without starting chemo. Patients with bone disease from myeloma are often started on a bisphosphonate.
Advanced myeloma
Patients whose myeloma is stage II or higher are often given drug therapy. The drugs chosen depend on the patient's health (including their kidney function) and whether or not a transplant is planned. (These drugs are discussed in more detail in the section, "Chemotherapy and other drugs.")
If the patient is not expected to have a transplant, chemotherapy with melphalan and prednisone (MP) may be used. Sometimes thalidomide is given with MP, but other drug combinations can be used as well.
Because it can have long-term effects on the bone marrow, MP is used less often if a transplant is planned. The combination of vincristine, doxorubicin (Adriamycin), and dexamethasone (VAD) once was often used before transplant, but now newer drugs are used more often. Most often a combination containing bortezomib (Velcade), thalidomide, or lenalidomide (Revlimid) plus dexamethasone is used.
Bisphosphonate treatment is often started along with chemo. If the areas of damaged bone continue to cause symptoms, radiation therapy may be used.
For an autologous transplant, stem cells are collected from the patient. Often this means treatment with chemo followed by daily doses of a drug that signals the body to make white blood cells. The stem cells are removed from the blood with a pheresis machine and stored until they are needed. Then, high doses of chemo are given to kill the myeloma cells. Most often, melphalan is the chemo drug used. Later, the patient gets back their own stem cells. The transplant may be repeated in 6 to 12 months if myeloma cells are still present.
Another possible treatment is allogeneic SCT. This may be able to cure the myeloma, but it has more severe side effects than the autologous transplant. Because they are so toxic, allogeneic transplants are only offered to younger patients who are otherwise in good health. The non-myeloablative allogeneic transplant may be a better option for some patients, such as those who are older.
Some patients are given additional cycles of treatment after transplant. This, called consolidation, increases the chance for a complete response (where signs and symptoms of the disease go away). This may be followed by long-term treatment with thalidomide or bortezomib. This is known as maintenance treatment, and helps delay the return of the myeloma, but it can cause serious side effects. The use of consolidation and maintenance treatment after standard drug therapy (without stem cell transplant) is being studied.
Many drug combinations can be useful in treating myeloma. If a drug stops working (or the myeloma comes back), others can be tried.
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